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pdfJanuary 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for data submission: 24 hours
MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
ADMINISTRATIVE DATA ELEMENTS
Public reporting burden for this collection of information is estimated to average 24 hours 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: MUSE
Administrative Data Elements
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for data submission: 24 hours
MUSE Administrative Data Elements
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.
Tribal Home Visiting grantees collect data for various purposes including:
•
•
•
•
•
Reporting participant demographics and service utilization to the Administration for Children
and Families (ACF)
Reporting performance measurement data to ACF
Reporting data to home visiting models for quality assurance and accreditation purposes
Conducting internal program monitoring and continuous quality improvement
Reporting to other funders
Grantees are being asked to submit data collected by the program for the purposes outlined above to
the MUSE study. While grantees submit aggregate data to ACF, in order to include these data in analyses
for MUSE, grantees will submit person-level data to the MUSE study team. Administrative data elements
requested include data about participating caregivers and children and the services they received.
Grantees will upload de-identified administrative data to a secure cloud-based document storage
system. The data grantees provide will be kept private. Only the MUSE study team and the grantee will
have access to this information. We will not report information collected in this study in a way that
could identify grantees, grantee staff, or any of the participants grantees are reporting data for.
The amount of time it takes to compile and submit the existing administrative data elements varies
depending on the number of caregivers who consent to participate in MUSE (including sharing
administrative data) at each grantee and the number of home visits provided to participants. It also
varies depending on the grantee’s data system and it’s reporting capabilities. For grantees using PAT and
NFP data systems, the MUSE Team will be able to obtain data files directly from the model which will
require only minimal involvement from the grantee. It will take grantees that are using PAT and NFP
data systems substantially less time to complete this instrument. On average, it will take grantees 24
hours to develop and run reports, and compile, clean and submit these data for a single submission.
Grantees will submit data semi-annually for a total of 4 times.
There is no required format or template for submitting administrative data, rather the MUSE study team
will accept a range of acceptable formats. Tribal Home Visiting grantees will work with MUSE and their
evaluation TA provider to determine the format for reporting that will be the least burdensome for each
site.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Administrative Data Elements
2
January 2019
DATA ELEMENT
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for data submission: 24 hours
RESPONSE CATEGORIES/DATA TYPE
Administrative Data Elements Collected for Reporting Participant Demographics and Service
Utilization to ACF
Sex
Male, Female
Age
<17, 18-19, 20-21, 22-24, 25-29, 30-34, 35-44, 45-54, 55-64, >65
Pregnancy status at enrollment
Y/N
Educational status
Student/Trainee, Not a Student/Trainee, Unknown/Did not report
Employment status
Employed full time, Employed part-time, Not employed,
Unknown/Did not report
Household income
Form dependent - dollar amount or income ranges
Child age at enrollment
Under 12 months, 12-24 months, 25-35 months, 37-60 months,
60-72 months, Unknown/did not report
Housing status
Not homeless, Homeless and sharing housing, Homeless and
living in an emergency or transitional shelter, Homeless with
some other arrangement, Unknown/Did not report
Type of health insurance
Not insured but has access to IHS, CHS, or UIHP facility; Not
insured and does not have access to IHS, CHS, or UIHP facility,
Medicaid or CHIP, TriCare, Private Insurance, Unknown/Did not
report
Race
AIAN, Asian, Black or African American, Native Hawaiian or other
Pacific Islander, White, More than one race including AIAN, More
than one race not including AIAN, Unknown/did not report
Child race
AIAN, Asian, Black or African American, Native Hawaiian or other
Pacific Islander, White, More than one race including AIAN, More
than one race not including AIAN, Unknown/did not report
Ethnicity
Hispanic or Latino, Not Hispanic or Latino, Unknown/did not
report
Marital status
Single, Legally married, Not married but living together with
partner, Separated/divorced/widowed, Unknown/did not report
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Administrative Data Elements
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for data submission: 24 hours
Educational attainment
Less than HS diploma, HS diploma/GED, Some college/training,
Technical training or certification, Associates degree, Bachelor's
degree or higher, Other, Unknown/did not report
Primary language spoken in
home
English, Spanish, Any Native language, Other, Unknown/did not
report
Secondary language spoken in
home
English, Spanish, Any Native language, Other, Unknown/did not
report
Administrative Data Elements Collected for Calculating and Reporting Performance Measurement
Data to ACF
Dates of screening for substance
abuse
DATE
Substance abuse screening itemlevel responses **These data are
optional. Grantees can opt out of
providing these data to MUSE.**
Item scores
Dates of screening for parental
depression
DATE
Depression screening total scores Total score
**These data are optional.
Grantees can opt out of providing
these data to MUSE.**
Dates of screening for unmet
basic needs (Family Resource
Check-in)
DATE
Screening for unmet basic needs
(Family Resource Check-in) item
level responses
Item scores
Dates of screening for
developmental delays
DATE
Results of screening for
developmental delay
Above cutoff/below cutoff
Dates of screening for intimate
partner violence
DATE
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Administrative Data Elements
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for data submission: 24 hours
Date of observation of caregiverchild interaction by the home
visitor
DATE
Expected visit frequency
Form dependent
Dates of changes to expected
visit frequency
DATE
Administrative Data Elements Collected for Home Visiting Model Reporting and/or Internal
Performance Monitoring and Continuous Quality Improvement
Caregiver age at enrollment
NUMBER
Caregiver relationship to index
child
Form dependent
Index child's birth month and
year
MONTH YEAR
Caregiver referral source to THV
Form dependent
Date of caregiver referral to THV
DATE
Date of caregiver enrollment in
THV
DATE
Dates of each missed visit
DATE
Reason for missed visit
Caregiver cancelled/Home visitor cancelled/Unable to confirm
visit/No-show
Dates of each home visit
completed
DATE
Home visitor completing each
home visit
NAME
Length of home visit
MINUTES
Date of caregiver exit from
program
DATE
Reason for caregiver exit from
program
Form dependent
Date of group events attended by
caregiver
DATE
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Administrative Data Elements
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| File Type | application/pdf |
| Author | [email protected] |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |