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pdfJanuary 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
CAREGIVER 6 & 12 MONTH FOLLOW-UP SURVEY
This collection of information is voluntary. Public reporting burden for this collection of information is estimated
to average 30 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 #: 0970-0521, Exp: 12/31/2021. 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].
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
1
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Staff member completes this page
Caregiver’s Program ID: _____
First name of staff member administering the survey or Staff ID: _____
Last name of staff member administering the survey or Staff ID (leave blank if using Staff ID): _____
Go to next page then hand tablet to caregiver
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
2
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
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 your
experiences with 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 30
minutes. If you are unsure how to answer a question, please give the best answer you can instead of
leaving it blank.
Do you want to take the survey?
Yes → GO TO Next Page
No → END Survey
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
3
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
A. BASIC QUESTIONS ABOUT YOURSELF
This section will ask questions about your personal background.
1. Are you or your partner currently pregnant or have you had a baby while participating in the home
visiting program?
Yes
No
2. How many children do you have? Please count any children that you are a primary caregiver for.
Select 0 if none. _____
3. What adults live 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
No other adults live with me
4. How many adults 18 years or older live in your household? If YOU are over 18, please include
yourself. Select 0 if none. _____
5. How many children between the ages of 6 and 17 live in your household? If YOU are under 18,
please include yourself. Select 0 if none. _____
6. How many children 5 years old or younger live in your household? Select 0 if
none. ______
7. 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
3-6 months
More than 6 months
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
4
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
B. EXPERIENCES IN HOME VISITING
1. How long have you been enrolled in the home visiting program?
Less than 6 months
6-8 months
9-11 months
12-14 months
More than 14 months
2. How often do you have home visits?
Weekly
About every 2 weeks
About every 3 weeks
About once a month
Less often than once a month
Don’t know
3. Do your home visits occur…
More often than you would like
Less often than you would like
Exactly as often as you would like
4. Who decides how often you have home visits?
It is totally my decision
It is mostly my decision
It is a decision my home visitor and I make equally
It is mostly my home visitor’s decision
It is totally my home visitor’s decision
5. Is your home visit length…
Longer than you would like
Shorter than you would like
Exactly as long as you would like
6. Who decides how long your home visits will be?
It is totally my decision
It is mostly my decision
It is a decision my home visitor and I make equally
It is mostly my home visitor’s decision
It is totally my home visitor’s decision
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
5
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
7. Think back to when the program was explained to you before you enrolled. How close are the
services you receive now to what you expected to receive?
Exactly what I expected
Very close to what I expected
A little different from what I expected
Not at all what I expected
8. How much do you agree or disagree with the following statements?
Strongly
disagree
Disagree
Agree
Strongly
agree
1
The home visiting program will help me reach my
personal goals.
2
The home visiting program will help my child reach his
or her full potential.
3
The home visiting program helps me feel good about
myself and my job as a parent.
4
The home visiting program is an excellent use of my
time.
5
The home visiting program helps me get the things I
need for my family.
9. How much has the support you have received in the home visiting program made a difference for
you in these areas?
1
2
3
4
5
A big
difference
Connecting with others to talk to as
supportive friends
Being more connected to my
community and culture (attending
community and/or cultural activities,
learning cultural teachings, making
new relationships with others in your
community)
Having my child be healthy
Feeding my child (including formula
and solids, and not including
breastfeeding)
My child’s development (learning new
physical and social skills, language
development, and coping with
emotions)
Some
difference
A little
difference
No
difference
Not
applicable
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
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January 2019
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7
8
9
10
11
12
13
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15
16
17
18
19
20
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22
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25
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OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
A big
difference
Managing my child's behavior
Making child care arrangements
Interacting with my child in a
supportive and positive way
Co-parenting with my child’s
father/mother
Taking care of my baby or child
(bathing, diapering, sleep, routines,
etc.)
Keeping my child and home safe
[SKIP if not currently pregnant] Having
a healthy pregnancy
[SKIP if not currently pregnant] Staying
healthy after I have my baby
Breastfeeding
Improving my overall health
Eating more nutritious meals and
exercising
Using family planning
Quitting smoking
Some
difference
A little
difference
No
difference
Not
applicable
Quitting alcohol or drugs
Dealing with stress
Dealing with sadness
Getting more education or job training
Getting a job, or getting a better job
Having healthy adult relationships
(with boyfriends/girlfriends,
husbands/wives, partners, co-parents)
Dealing with partner or family
violence
Coping with my own past abuse or
trauma
Meeting basic needs such as food,
utilities, housing, transportation, and
obtaining identification
Budgeting/making ends meet
Legal system and services
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
7
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
C. SETTING GOALS
1. Have you and your home visitor ever talked about your goals and developed a plan for reaching
them? This might include making a list of goals that you would like to accomplish and steps you
could take to reach those goals.
Yes
No → SKIP to Section D question 1.
Not sure → SKIP to Section D question 1.
2. How were your goals identified?
I identified the goals myself
I identified the goals with help from my home visitor
My home visitor identified the goals with help from me
My home visitor identified the goals for me
3. Was YOUR role in setting the goals…
Bigger than you would have liked
Smaller than you would have liked
Just right
4. How similar or different are the goals you identified to what you were originally hoping for when
you started home visiting?
Very similar
Similar
Different
Very different
5. How satisfied or dissatisfied are you with the goals you set?
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
6. About how often do you and your home visitor talk about your goals?
Never
Hardly any visits
Some visits
Most visits
Every visit
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
8
January 2019
D.
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
WHAT HAPPENS IN HOME VISITS
1. Who usually decides what you talk about and do in home visits?
It is totally my decision
It is mostly my decision
It is a decision my home visitor and I make equally
It is mostly my home visitor’s decision
It is totally my home visitor’s decision
2. Have you ever talked about the following topics with your home visitor?
1
2
3
4
5
6
7
8
9
10
11
12
13
Connecting with others to talk to as supportive friends
Being more connected to my community and culture
(attending community and/or cultural activities, learning
cultural teachings, making new relationships with others
in your community)
Having my child be healthy
Feeding my child (including formula and solids, and not
including breastfeeding)
My child’s development (learning new physical and social
skills, language development, and coping with emotions)
Managing my child's behavior
Making child care arrangements
Interacting with my child in a supportive and positive way
Co-parenting with my child’s father/mother
Taking care of my baby or child (bathing, diapering, sleep,
routines, etc.)
Keeping my child and home safe
[SKIP if not currently pregnant] Having a healthy
pregnancy
[SKIP if not currently pregnant] Staying healthy after I
have my baby
Breastfeeding
Improving my overall health
Eating more nutritious meals and exercising
Using family planning
Quitting smoking
Quitting alcohol or drugs
Yes
No
Not
applicable
14
15
16
17
18
19
20
Dealing with stress
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
9
January 2019
21
22
23
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26
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28
29
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Dealing with sadness
Getting more education or job training
Getting a job, or getting a better job
Having healthy adult relationships (with
boyfriends/girlfriends, husbands/wives, partners, coparents)
Dealing with partner or family violence
Coping with my own past abuse or trauma
Meeting basic needs such as food, utilities, housing,
transportation, and obtaining identification
Budgeting/making ends meet
Legal system and services
Yes
No
Not
applicable
3. How important is it to you to be able to talk about these topics with your home visitor?
Not at all Minimally Somewhat
Very
Not
important important important important applicable
1
2
3
4
5
6
7
8
Connecting with others to talk
to as supportive friends
Being more connected to my
community and culture
(attending community and/or
cultural activities, learning
cultural teachings, making
new relationships with others
in your community)
Having my child be healthy
Feeding my child (including
formula and solids, and not
including breastfeeding)
My child’s development
(learning new physical and
social skills, language
development, and coping
with emotions)
Managing my child's behavior
Making child care
arrangements
Interacting with my child in a
supportive and positive way
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
10
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Not at all Minimally Somewhat
Very
Not
important important important important applicable
28
Co-parenting with my child’s
father/mother
Taking care of my baby or
child (bathing, diapering,
sleep, routines, etc.)
Keeping my child and home
safe
[SKIP if not currently
pregnant] Having a healthy
pregnancy
[SKIP if not currently
pregnant] Staying healthy
after I have my baby
Breastfeeding
Improving my overall health
Eating more nutritious meals
and exercising
Using family planning
Quitting smoking
Quitting alcohol or drugs
Dealing with stress
Dealing with sadness
Getting more education or
job training
Getting a job, or getting a
better job
Having healthy adult
relationships (with
boyfriends/girlfriends,
husbands/wives, partners, coparents)
Dealing with partner or family
violence
Coping with my own past
abuse or trauma
Meeting basic needs such as
food, utilities, housing,
transportation, and obtaining
identification
Budgeting/making ends meet
29
Legal system and services
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
11
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
4. My home visitor spends most of his/her time…
Talking with me
Talking with my child
Talking with both my child and me
5. What happens if other family members (other than the index child) are with you
during a visit?
My home visitor focuses on me and my child
My home visitor talks with all family members but mainly focuses on me and my child
My visitor includes all family members in visit activities
This has never happened; it’s always just me and my child
6. The amount of time my home visitor spends filling out paperwork DURING visits
is…
More than I would like
Less than I would like
About the right amount
7. How much do you agree or disagree with each of the following statements?
Strongly
Strongly
Disagree Agree
disagree
agree
1
2
3
4
5
6
I prefer to choose visit topics and activities myself rather
than have the home visitor choose them.
[SKIP if '0' children] I like it when my home visitor
suggests ways to do things better as a parent.
I appreciate when my home visitor gives me an
opportunity to talk about my mental health, substance
abuse, or partner violence.
[SKIP if '0' children] If my home visitor raises a concern
about my parenting, it shows that she or he cares for
and respects my family.
[SKIP if '0' children] I prefer my home visitor to focus on
the things I do well as a parent.
I prefer for the home visitor to lead the visit. She or he
can decide what we talk about and do.
If my home visitor asks about my mental health,
7 substance use, or relationship with my partner, it is
because she or he cares about me and my family.
[SKIP if '0' children] I would feel offended if my home
8 visitor raised a concern about how I am parenting my
child.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
12
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
E. EXPERIENCES WITH YOUR HOME VISITOR
1. How much do you agree or disagree with the following statements? My home visitor is…
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Flexible
Inflexible
Supportive
Caring
Judgmental
Knowledgeable
Accepting
Unprofessional
Good listener
Dependable
Pushy
Trustworthy
Available when I need her/him
Understanding
Disrespectful
Humble
Interested in knowing more about me
Strongly
disagree
Disagree
Agree
Strongly
agree
2. How much do you agree or disagree with the following statements?
My home visitor wants me to tell her/him how I would
like to spend the time during home visits.
My home visitor wants me to let her/him know if I
2
don’t understand something.
My home visitor wants me to decide what we do in
3
visits.
My home visitor wants me to let her/him know if I
4
disagree with something she/he says.
1
Strongly
disagree
Disagree
Agree
Strongly
agree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
13
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
3. How often are the conversations and activities during visits interesting to you?
Never
Rarely
Sometimes
Often
Always
4. When I am bored or not interested in a topic or activity my home visitor…
Frequently does not notice
Encourages me to continue anyway
Suggests another topic or activity
Asks what I would prefer to do
5. How often does your home visitor do the following:
Hardly
any
visits
Never
1 Gives me positive feedback.
Shows warmth, respect, and appreciation to my
2
family.
Shows that she/he wants to understand my
3
perspective, concerns, and feelings.
Makes sure that visit activities match my interests,
4
concerns, and preferences.
Balances my interests with those of the home visiting
5
program.
Some
visits
Most
visits
Every
visit
6. Below are statements about some things home visitors may do. How much do you agree or disagree
with each of the following statements?
Strongly
Disagree
disagree
My home visitor . . .
1 …plans visits according to what I prefer.
…asks me about and addresses family
2 concerns, even if this means changing
planned activities.
…makes sure I understand what we are
3
talking about before moving on.
…focuses conversation and activities to fit
4
my interests.
Agree
Strongly
agree
Not
sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
14
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
7. Below are statements that describe how a parent might feel about her/his home visitor. How often
do you think or feel that way? For example, if the statement describes the way you always think or
feel, select the “Always”.
Never Rarely
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
How often do you think or feel this way?
My home visitor and I agree about the things I
will need to do to benefit me and my family.
Sometimes
Often
Always
What I am doing with home visiting gives me
new ways of looking at my family's situation.
There are certain things I wouldn’t say in front
of my home visitor, even though we’re close.
I believe my home visitor likes me.
My home visitor does not understand what I
am trying to accomplish with home visiting.
I can talk to my home visitor about personal
matters.
I am confident in my home visitor's ability to
help me.
My home visitor and I are working toward
mutually agreed upon goals.
I feel that my home visitor appreciates me.
My home visitor and I don’t really see eye to
eye. She/he has given me advice that I
disagree with.
We agree on what is important for me to
work on.
My home visitor and I trust one another.
My home visitor and I have different ideas on
what I want and need.
There are certain things about my home
visitor that make it hard for me to relate to
her/him.
We have established a good understanding of
the kind of changes that would be good for
me.
My home visitor respects my community and
culture.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
15
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
8. The following statements describe different ways that home visitors might interact with families.
How often does your home visitor interact with you and your family in the following ways?
Never
Hardly
any
visits
Some
visits
Most
visits
Every
visit
My home visitor really listens to my concerns or
requests.
My home visitor sees my family in a positive
2
way.
My home visitor gives me information to make
3
good choices.
My home visitor responds to my requests for
information or guidance.
My home visitor tries hard to understand my
5
family.
My home visitor recognizes my family’s
6
strengths.
My home visitor empowers me to get the
7
resources and support I need.
1
4
8
My home visitor is flexible when my family’s
situation changes.
9. How likely is it that you would tell to your home visitor that you:
Very
unlikely
1 Had not followed her/his suggestion?
2 Disagreed with her/him?
Are getting different advice from family or
3
friends?
Somewhat Somewhat
unlikely
likely
Very
likely
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
16
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
F. YOUR RELATIONSHIPS AND WELLBEING
1. The next questions are about your relationships with other people. How much do you agree or
disagree with 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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
There are people I know will help me if I really need
it.
There are people who call on me to help them.
There are people who like the same social activities I
do.
I feel responsible for taking care of someone else.
I am with a group of people who think the same way I
do about things.
There are people I can count on when I need help as
a parent.
I have close relationships that make me feel good.
I have someone I can go to with questions about
parenting.
I have someone to talk to about decisions in my life.
There are people who value my skills and abilities.
I have a trustworthy person to turn to if I have
problems.
I feel a strong emotional tie with at least one other
person.
There are people who admire my talents and
abilities.
There are people I can count on in an emergency.
Agree
Strongly
agree
2. [SKIP if '0' children] How much do you agree or disagree with the following statements?
Strongly
disagree
1
2
The problems of taking care of a child are easy to
solve once you know how your actions affect your
child, like I do.
I would make a good model for a new parent to
follow.
Disagree
Agree
Strongly
agree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
17
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Strongly
disagree
3
4
5
6
7
Disagree
Agree
Strongly
agree
Being a parent is manageable, and any problems are
easily solved.
I am an expert in caring for my child.
If anyone can find the answer to what is troubling my
child, I am the one.
I am comfortable in my role as a parent.
I have all the skills necessary to be a good parent to
my child.
3. [SKIP if '0' children] The following statements describe different ways that parents interact with their
children on a daily basis. How often is each statement true for you?
When I am with my child, I have difficulty
staying focused on what is happening in the
present.
I rush through activities with my child
2
without being really attentive to him/her.
I am often so busy thinking about other
3 things that I am not really listening to my
child.
I am aware of how my moods affect the way
4
I treat my child.
When I'm upset with my child, I notice how I
5
am feeling before I take action.
When I am upset with my child, I calmly tell
6
him/her how I am feeling.
I notice how changes in my child’s mood
7
affect my mood.
I often react too quickly to what my child
8
says or does.
When I am feeling stressed, it is hard to pay
9
enough attention to my child.
I can usually manage stressful things that
10
happen and still take care of my child.
1
Never
true
Rarely
true
Sometimes
true
Often Always
true
true
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
18
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
4. [SKIP if '0' children] How much do you agree or disagree with the following statements?
1
2
3
4
I am comfortable being a parent because my
family and community are there to help me.
Working together with family and friends, I can
solve many of the problems of caring for my
child.
Being a parent is manageable with the support
of my family and friends.
I am good at caring for my child because of what
I have learned from my family and community
about parenting.
Strongly
disagree
Disagree
Agree
Strongly
agree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
19
January 2019
OMB Control NO.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
G. FINAL THOUGHTS
1. Now we would like you to think about your overall experience with the home visiting program. How
much do you agree or disagree with each of the following statements?
What I get out of the home visiting program is worth
the time it takes to participate.
There are some things I do differently now because of
2
my experience in the home visiting program.
I would recommend the home visiting program to my
3
family and friends.
1
Strongly
disagree
Disagree
Agree
Strongly
agree
[NEXT SCREEN]
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS
SURVEY.
Please click ‘submit’ to exit the survey.
[NEXT SCREEN]
Please stop here and return the tablet back to your
home visitor.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6
& 12 Month Follow-Up Survey
20
| File Type | application/pdf |
| Author | Nancy Whitesell;[email protected] |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |