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pdfJanuary 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
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 #: 0970-0521, 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 Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 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 Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 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 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.
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 Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
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
No
3. Do you already have children?
Yes →SKIP TO Question 3a
No →SKIP TO Question 4
3a. [SKIP if Question 3 = NO] How many children do you have? Please count any children that
you are a primary caregiver for. Select 0 if none. _____
3b. [SKIP if Question 3 = NO or Question 3a = 0] How many children do you
have under age 5? Please count any children that you are a primary
caregiver for. Select 0 if none. _____
Yes
No
4. Have you ever helped raise any children other than your own?
Yes
No
5. 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
6. How many adults 18 years or older live in your household? If YOU are over 18, please include
yourself. Select 0 if none. _____
7. 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. _____
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
8. How many children 5 years old or younger live in your household? Select 0 if
none. _____
9. 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
10. What language do you prefer for visits?
English
My tribal language
Spanish
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
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. How important were these
reasons in your decision to enroll?
Not
Somewhat
important Important
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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
Important
Very
important
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
Not
Somewhat
important Important
19
20
21
22
23
24
25
26
27
28
29
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
Important
Very
important
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
C. 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
2.
1
2
3
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
Disagree
Agree
Strongly
agree
[SKIP if you do not have children yet, Question A3 = No]
How much do you agree or disagree with the following statements?
Strongly
disagree
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.
Being a parent is manageable, and any problems are
easily solved.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
4
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
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.
5
6
7
3.
[SKIP if you do not have children yet, Question A3 = No]
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 or 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 or 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
4.
Never
true
Rarely
true
Sometimes
true
Often Always
true
true
[SKIP if you do not have children yet, Question A3 = No]
How much do you agree or disagree with the following statements?
Strongly
disagree
Disagree
Agree
Strongly
agree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline
Survey
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January 2019
1
2
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 15 minutes
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.
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 ‘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 Baseline
Survey
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| File Type | application/pdf |
| Author | Nancy Whitesell;[email protected] |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |