Instrument G-Referral staff survey_V3_clean

Referral Staff Survey OMB Control Number: 0970-0531

Expiration Date: 7/31/2022

^{Referral staff survey}

Survey of referral staff

Introduction

A research organization named Mathematica is working with Viability to improve the MOMS Partnership program. We are going to ask you some questions about how you refer people to the MOMS Partnership. The answers to your questions will help improve the referral process. It should take about 5 minutes to complete this survey.

You can decline to complete the survey or leave any questions blank. Your individual response will not be associated with your name. All responses will be combined; no one outside the research team will know how you responded.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to gather information for the purpose of rapid-cycle learning activities to strengthen programs. 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 #: 0970-0531, Exp: 07/31/2022. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Sheena McConnell; [email protected]

1. To what extent do you agree or disagree with the following statements?

Statement	Strongly disagree	Disagree	Agree	Strongly agree	Not sure
The messaging about MOMS Partnership and the study is clear.	1 	2 	3 	4 	5
I have ideas for how I will recruit and refer people to MOMS Partnership.	1 	2 	3 	4 	5 
I know how to identify people who are a good fit for MOMS Partnership.	1 	2 	3 	4 	5 
I am likely to refer people to MOMS Partnership.	1 	2 	3 	4 	5 

2. If there is anything else you need to know about MOMS Partnership to help with recruitment, please tell us in the box below. [Open text box]

3. If you have any concerns about MOMS Partnership, please share them in the box below. [Open text box]

2