3 Family Online Survey

OMB Control #: XXXX-XXXX

Expiration Date: XX/XX/XXXX

INSTRUMENT 3: Family Survey

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0906-XXXX. This information collection aims to explore how families that experience disparities in outcomes targeted by the MIECHV program experience home visiting services. This study is an initial step in understanding those experiences and will provide a better understanding of how MIECHV-funded home visiting programs currently address disparities and promote equity. Data collection activities include interviews, focus groups, online surveys, program observations, and review of documents and management information systems data. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and confidentiality is followed according to law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD or [email protected]. 

[Online survey to be programmed in Qualtrics]

Family Survey

Introduction and Consent

We invite you to participate in this voluntary data collection for the Home Visiting Assessments of Implementation Quality (HV-AIM) project. The survey is designed to understand your experiences with your home visitor and home visiting services. The survey asks questions about feelings of inclusion and respect within home visiting, experiences of microaggressions, and feelings of whether your identity as a Black caregiver is acknowledged and affirmed.

Some of the questions asked in the survey may cause discomfort or remind you of difficult situations or experiences. You have the right to skip questions and stop participation at any time. Although you do not receive any direct benefits from participation, your stories and input will help to improve services for other families. There are no foreseeable risks involved in participating in this research beyond those experienced in everyday life.

Your responses will be kept strictly private to the extent permitted by law. Only the HV-AIM project team will have access to this information. If you participate in a follow-up interview, some responses you share in this survey may be discussed during the interview. Your answers will not be shared with your home visitor or anyone else at your home visiting program. Your responses will be combined with responses from other participants and shared in a report prepared for the Health Resources and Services Administration. In our research report, the information you provide will not be assigned to you by name.

The survey will take approximately 30 minutes to complete. If you complete this survey, we will send you a $35 gift card as a thank you. At the end of the survey, we will ask if you would like to receive the gift card by email or mail.

If you are unable to complete your survey all at once, you can exit the survey (by closing your internet browser window) and return to complete it later. To restart your survey, click on the survey link that was sent to you. Once you click "submit", you will not be able to make changes to your survey. Please email [email protected] if you have any issues with the survey or your survey link.

By clicking “Next,” you consent to participate in this survey. Click “Next” to begin.

Section A. Demographics

First, we would like you to tell us about yourself.

1. First and Last Name: [open text field]

2. Email address: [open text field]

3. I identify my race or ethnicity as (please select all that apply):

1. American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

2. Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)

3. Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)

4. Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)

5. Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)

6. Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

7. White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)

8. Prefer not to answer

4. I consider myself a descendant of enslaved people in America:

   1. Yes

   2. No

   3. I prefer not to answer

5. Are you: Mark all that apply.

   1. Female

   2. Male

   3. Transgender, non-binary or another gender

   4. I prefer not to answer

6. I am:

1. Under 18 years old

2. 18-21 years old

3. 22-29 years old

4. 30-44 years old

5. 45 years old or older

7. I consider my neighborhood to be:

6. Urban

7. Suburban

8. Rural

Next, we would like to know a little bit about your enrollment in home visiting services.

8. Are you currently enrolled in home visiting services?

1. Yes

2. No

3. If yes: How long have you been enrolled in home visiting services?

   1. Less than 6 months

   2. 6–12 months

   3. More than 1 year

      1. For your child who is enrolled in home visiting, how do you identify their race or ethnicity (please select all that apply)?

         1. American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

         2. Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)

         3. Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)

         4. Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)

         5. Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)

         6. Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

         7. White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)

         8. Prefer not to answer

      2. For your child who is enrolled in home visiting, what is their age?

1. Less than 6 months old

2. 6-12 months old

3. 1-2 years old

4. 3-4 years old

5. 5 years old

6. More than 5 years old

1. If no: How long were you enrolled in home visiting services before stopping?

   1. Less than 6 months

   2. 6–12 months

   3. More than 1 year

      1. For your child who was enrolled in home visiting, how do you identify their race or ethnicity (please select all that apply)?

         1. American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

         2. Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)

         3. Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)

         4. Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)

         5. Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)

         6. Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

         7. White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)

         8. Prefer not to answer

      2. For your child who was enrolled in home visiting, what is their age?

1. Less than 6 months old

2. 6-12 months old

3. 1-2 years old

4. 3-4 years old

5. 5 years old

6. More than 5 years old

9. Why did you decide to enroll in home visiting services (please select all that apply)?

1. To receive general advice and support

2. To receive parenting support and information

3. To learn ways to improve the health or well-being of your child(ren)

4. To get financial assistance or complete education or job training goals

5. To learn more about services available in your community

6. Other (please specify): [open text field]

10. Do you share the same racial identity with your home visitor?

1. Yes

2. No

3. Unsure

11. There are a few additional opportunities to participate in the HV-AIM project. We will hold a small group discussion with other Black caregivers to talk about their experiences in home visiting. Small group discussion participants will receive a $50 gift card. Also, we would like to form a family advisory group to share project findings with and discuss suggestions for improving home visiting programs based on project findings. Advisory board members would receive financial reimbursement for their time. Can we reach out to you in the future to see if you are interested in participating in these additional opportunities?

1. Yes

2. No

22. If yes: Enter your phone number if you would like us to reach out to you by text message: [open text field]

Section B. Race and Parenting

The next questions will help us understand your experiences related to race and parenting. Please share your level of agreement with the following statements.

	Strongly disagree	Disagree	Somewhat disagree	Somewhat agree	Agree	Strongly agree	I prefer not to answer
My home visitor discusses how racism impacts parenting.	6	5	4	3	2	1	0
My home visitor seems aware of how my child’s race might impact my parenting goals and priorities.	6	5	4	3	2	1	0
My home visitor understands my experiences as a Black caregiver.	6	5	4	3	2	1	0
My home visitor asks me about my goals related to helping my child understand race and racism.	6	5	4	3	2	1	0
I will expose my child to positive images of their race so that they are proud to be who they are.	6	5	4	3	2	1	0
I will make sure my child knows that White people and people of other races may not always work in their best interest.	6	5	4	3	2	1	0
I will tell my child that people are people, and they should not see race.	6	5	4	3	2	1	0
I will make sure my child knows how to respond when they experience racism and discrimination based on their identity as a Black child.	6	5	4	3	2	1	0

Section C. Experiences with Your Home Visitor

The next questions will help us understand your experiences with your home visitor. Please share your level of agreement with the following statements.

A. While working with my home visitor to make decisions about my family’s health and well- being:
	Strongly disagree	Disagree	Somewhat disagree	Somewhat agree	Agree	Strongly agree	I prefer not to answer
My family or cultural traditions are supported	6	5	4	3	2	1	0
B. I feel like I am treated poorly by my home visitor because of:
	Strongly disagree	Disagree	Somewhat disagree	Somewhat agree	Agree	Strongly agree	I prefer not to answer
My race	6	5	4	3	2	1	0
My ethnicity	6	5	4	3	2	1	0
My culture	6	5	4	3	2	1	0
My language	6	5	4	3	2	1	0
My sexual orientation	6	5	4	3	2	1	0
My gender identity	6	5	4	3	2	1	0

Section D. Discussions of Race with Your Home Visitor

The next questions will help us understand your experiences related to discussing race and your racial identity with your home visitor. Please check the response that best describes your experience.

	This never happened	This happened, but it did not bother me at all	This happened and I was bothered by it
My home visitor avoided discussing or addressing racial issues in our visit(s).
My home visitor sometimes was insensitive about my racial group when trying to understand or discuss my racial experiences.
My home visitor seemed to deny having any racial biases or stereotypes.
My home visitor may have thought at times that I was overly sensitive about racial issues.
My home visitor at times seemed to over-identify with my experiences related to my race or culture.
My home visitor at times seemed to have stereotypes about my racial group, even if they did not express them directly.
My home visitor sometimes seemed unaware of the realities of race and racism.
My home visitor at times may have either overestimated or underestimated my abilities or strengths based on my racial group membership.
My home visitor sometimes minimized the importance of racial issues in our session(s).
My home visitor may have offered services that were inappropriate or unneeded based on my racial group membership.

Section E. Additional Information

Your input and experience are valued. Is there anything else you would like to share about the topics and questions asked in the survey? (Optional)” [Text box]

Sometimes questions such as those in the survey may cause discomfort or cause you to reflect on past situations you may have experienced. People often feel better after they talk with someone.

If any questions remind you of an experience or is something you want to address with your home visiting program, we recommend you reach out to your home visiting program director or supervisor.

If you do not want to talk with someone you know, feel free to reach out to the HV-AIM project team at [email protected]. You can also reach out if you have any questions or want more information about the study.

Section F. Gift Card

Thank you so much for taking the time to provide us with this important information. We would like to send you a $35 gift card. Please let us know how you would like to receive your gift card:

1. Email my gift card to: [enter email address]

2. Mail my gift card to: [enter mailing address]

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