7 Instrument 9- MCHB- Assessing the Use of Coaching - 6.5.

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

Focus Group Participant Characteristics Form

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 form? This form aims to collect demographic data from all ADAPT-HV focus group participants to describe the characteristics of the focus group sample.

There are no risks or benefits to your participation. Your participation in this form 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 complete this form.

The form should take roughly 5 minutes to complete. Your name is NOT connected to this form, and the information you provide will be kept private to the extent permitted by law.

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: This collection of information will be used to learn about demographic characteristics of focus group participants. 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 control number for this information collection is 0915/0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Given what you just read about the purpose of this project, please select a response below.

• I agree to provide my demographic information to help the ADAPT-HV project describe the characteristics of the focus group sample. [go to Q1]

• I do not agree to provide my demographic information. I understand that there is no penalty for not answering these questions. [exit form

[FORM A - Program Staff Focus Group Participants]

1. What age range do you fall into?

   • 18 to 24

   • 25 to 34

   • 35 to 44

   • 45 to 54

   • 55 to 64

   • 65 to 74

   • 75 or older

2. Are you: Select all that apply.

• Female

• Male

• Transgender, non-binary, or another gender

• I identify another way (please specify): ___________

3. What is your race or ethnicity (select all that apply)?

   • American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit)

   • Asian (e.g., Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese)

   • Black or African American (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali)

   • Hispanic or Latino (e.g., Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian)

   • Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli)

   • Native Hawaiian or Other Pacific Islander (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese)

   • White (e.g., German, Irish, English, Italian, Polish, French)

   • I prefer not to answer

4. How long have you worked at your current organization?

• Less than 1 year

• 1 to 5 years

• More than 5 years

5. What position do you currently hold at your current organization? Select all that apply.

   • Director

   • Manager

   • Supervisor

   • Home visitor or related service provider

   • Support staff

   • Other program staff (please specify): ____________

6. For how long have you held this position?

• Less than 1 year

• 1 to 5 years

• More than 5 years

[FORM B - Family Focus Group Participants]

1. What age range do you fall into?

   • 18 to 24

   • 25 to 34

   • 35 to 44

   • 45 to 54

   • 55 to 64

   • 65 to 74

   • 75 or older

2. Are you: Select all that apply.

• Female

• Male

• Transgender, non-binary, or another gender

• I identify another way (please specify): ___________

3. What is your race or ethnicity (select all that apply)?

   • American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit)

   • Asian (e.g., Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese)

   • Black or African American (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali)

   • Hispanic or Latino (e.g., Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian)

   • Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli)

   • Native Hawaiian or Other Pacific Islander (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese)

   • White (e.g., German, Irish, English, Italian, Polish, French)

   • I prefer not to answer

4. How old is the child with whom you are participating in home visiting services?

   • Newborn (0 to less than 3 months old)

   • Infant (3 months to less than 1 year old)

   • 1 year to less than 2 years old

   • 2 years to less than 4 years old

   • 4 years to 5 years old

5. For how many children under the age of 18 are you currently considered the primary caregiver? Please include the child with whom you are participating in home visiting services in this count.

_____ [write-in, numeric]

Thank you for submitting this form!

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.