OMB No: 0906-XXXX
Expiration Date: XX/XX/20XX
Home Visitor Questionnaire
Health Resources & Services Administration Maternal and Child Health Bureau ADAPT-HV |
The Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency (ADAPT-HV) project is funded by the Health Resources and Services Administration (HRSA) through a contract with The Policy & Research Group (PRG) and Mathematica.
What is the purpose of this questionnaire? This questionnaire aims to understand home visitors’ use of strategies to conduct effective coaching when appropriate over each learning cycle of the ADAPT-HV study.
There are no risks or benefits to your participation. Your participation in this questionnaire is voluntary. You have the right to skip any question or end your participation at any time. There is no penalty if you choose not to participate in this questionnaire.
In order to know who has completed this questionnaire, we ask for your name and the name of the agency for which you work. This information will be removed when data are saved. We will not attribute any responses you give in the questionnaire to you personally and will not use your name when results from the research are shared. Only the research team will have access to individual responses. Your responses will be combined with other responses before results are reviewed. All data will be stored safely and destroyed at the end of the study.
The questionnaire should take roughly 10–15 minutes to complete.
If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group ([email protected] or (225) 281-3783).
If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982. |
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 will be used to assess nominated ECHV programs’ interest in and eligibility for participation in the Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency (ADAPT-HV) study. The time required to complete this information collection is estimated to average less than 0.17 hours 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].
Given what you just read about the purpose of this project, please select a response below.
I agree to provide my feedback on the home visiting services I’ve provided to help the ADAPT-HV project to learn how to better deliver home visiting services.
I do not agree to provide my feedback on the home visiting services I’ve provided. I understand that there is no penalty for not answering these questions. [exit form]
Please enter your name and your agency’s name below so that we know who has completed this questionnaire. |
First name: [write-in]
Last name: [write-in]
Agency/organization name: [write-in]
COACHING STRATEGIES IMPLEMENTED This section asks about the number of families with whom you have implemented strategies to conduct effective coaching when appropriate during home visits over the past week (7 days). We know the use of these strategies or coaching techniques may not be appropriate for each family or during each home visit, but we would like to know about the number of visits in which you did use the strategy to improve services. The questions will reference the specific coaching strategies your site has identified to test during this learning cycle through the ADAPT-HV study. As a reminder, those strategies are listed below.
|
*Contents of this box and some subsequent questions will be customized for each site based on the strategies they identified to test in collaboration with the ADAPT-HV study team during staff focus groups conducted during Phases 1, 2, and/or 3.*
In total, how many families are you serving at this time (i.e., what is your current caseload?)
Write-in
Of the [numeric response from Q2] in-person home visits you conducted this week, during how many did you use [strategy 1]?
Numeric drop down – maximum limit response from Q2
[if applicable]
Of the [numeric response from Q2] in-person home visits you conducted this week, during how many did you use [strategy 2]?
Numeric drop down – maximum limit response from Q2
Of the [numeric response from Q4] virtual home visits you conducted this week, during how many did you use [strategy 1]?
Numeric drop down – maximum limit response from Q4
[if applicable]
Of the [numeric response from Q4] virtual home visits you conducted this week, during how many did you use [strategy 2]?
Numeric drop down – maximum limit response from Q4
STRATEGY CHALLENGES AND SUCCESSES This section asks about challenges and successes that you may have encountered when implementing the strategies of interest during home visits in the past week. |
[if number of visits reported in Q3a is >0 or Q5a is >0]
Briefly describe any challenges you experienced using [strategy 1] in the past week. Please specify whether the challenge(s) occurred during in-person or virtual home visits.
Open-ended response
Briefly describe any successes you experienced using [strategy 1] in the past week. Please specify whether the success(es) occurred during in-person or virtual home visits.
Open-ended response
[if number of visits reported in Q3b is >0 or Q5b is >0]
Briefly describe any challenges you experienced using [strategy 2] in the past week. Please specify whether the challenge(s) occurred during in-person or virtual home visits.
Open-ended response
Briefly describe any successes you experienced using [strategy 2] in the past week. Please specify whether the success(es) occurred during in-person or virtual home visits.
Open-ended response
[if applicable]
EXPERIENCES WITH STRATEGY IMPLEMENTATION This section asks about your thoughts and feelings on your experiences implementing the strategies of interest during home visits in the past week. |
Experiences with [strategy 1] |
On a scale from 1 to 5, how often would you say caregiver–child interaction improved/benefitted because of your use of [strategy 1] over the past week?
By caregiver–child interaction, we mean the reciprocal relationship, communication, emotional exchanges, and responses between a child and their caregiver.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say a child’s engagement or participation improved/benefitted because of your use of [strategy 1] over the past week?
By engagement or participation we mean how interested or involved the child appeared.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say your rapport with your families improved/ benefited because of your use of [strategy 1] over the past week?
By rapport, we mean a relationship characterized by agreement, mutual understanding, or empathy that makes communication possible or easy, demonstrated by friendly interaction, ease of communication, and/or feeling of emotional connection.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say [strategy 1] contributed to [immediate goal of strategy 1] over the past week?
Never
Rarely
Occasionally
Almost every time
Every time
*Contents of this question will be customized for each site based on the expected benefits discussed with the ADAPT-HV study team during program staff focus groups in Phase 1, if applicable, in order to build flexibility for sites to define outcomes of interest.
[if number of visits reported in Q3a is >0]
On a scale from 1 to 5, how confident are you in your ability to implement [strategy 1] effectively during in-person visits?
Not at all confident
Slightly confident
Somewhat confident
Moderately confident
Extremely confident
[if number of visits reported in Q5a is >0]
On a scale from 1 to 5, how confident are you in your ability to implement [strategy 1] effectively during virtual visits?
Not at all confident
Slightly confident
Somewhat confident
Moderately confident
Extremely confident
[if number of visits reported in Q3a is >0]
On a scale from 1 to 5, how comfortable do you feel implementing [strategy 1] during in-person visits?
Not at all comfortable
Slightly comfortable
Somewhat comfortable
Moderately comfortable
Extremely comfortable
[if number of visits reported in Q5a is >0]
On a scale from 1 to 5, how comfortable do you feel implementing [strategy 1] during virtual visits?
Not at all comfortable
Slightly comfortable
Somewhat comfortable
Moderately comfortable
Extremely comfortable
[if applicable]
Experiences with [strategy 2] |
On a scale from 1 to 5, how often would you say caregiver-child interaction improved/benefitted because of your use of [strategy 2] over the past week?
By caregiver–child interaction, we mean the reciprocal relationship, communication, emotional exchanges, and responses between a child and their caregiver.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say a child’s engagement or participation improved/benefitted because of your use of [strategy 2] over the past week?
By engagement or participation we mean how interested or involved the child appeared.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say your rapport with your families improved/ benefited because of your use of [strategy 2] over the past week?
By rapport, we mean a relationship characterized by agreement, mutual understanding, or empathy that makes communication possible or easy, demonstrated by friendly interaction, ease of communication, and/or feeling of emotional connection.
Never
Rarely
Occasionally
Almost every time
Every time
On a scale from 1 to 5, how often would you say [strategy 2] contributed to [immediate goal of strategy 2] over the past week?
Never
Rarely
Occasionally
Almost every time
Every time
*Contents of this question will be customized for each site based on the expected benefits discussed with the ADAPT-HV study team during program staff focus groups in Phase 1, if applicable, in order to build flexibility for sites to define outcomes of interest.
[if number of visits reported in Q3b is >0]
On a scale from 1 to 5, how confident are you in your ability to implement [strategy 2] effectively during in-person visits?
Not at all confident
Slightly confident
Somewhat confident
Moderately confident
Extremely confident
[if number of visits reported in Q5b is >0]
On a scale from 1 to 5, how confident are you in your ability to implement [strategy 2] effectively during virtual visits?
Not at all confident
Slightly confident
Somewhat confident
Moderately confident
Extremely confident
[if number of visits reported in Q3b is >0]
On a scale from 1 to 5, how comfortable do you feel implementing [strategy 2] during in-person visits?
Not at all comfortable
Slightly comfortable
Somewhat comfortable
Moderately comfortable
Extremely comfortable
[if number of visits reported in Q5b is >0]
On a scale from 1 to 5, how comfortable do you feel implementing [strategy 2] during virtual visits?
Not at all comfortable
Slightly comfortable
Somewhat comfortable
Moderately comfortable
Extremely comfortable
Thank you for completing this questionnaire!
If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group ([email protected] or (225) 281-3783).
If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982. |
The
Policy & Research Group
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Catie Henley |
| File Modified | 0000-00-00 |
| File Created | 2024-07-20 |