Tribal Home Visiting Continuous Quality Improvement Collaboratives

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CQIC Family of Measures Survey
Tribal Home Visiting Resource Institute for Excellence
[Please note this form will be entered into Qualtrics for data entry.]
Introduction 
This survey is intended to measure the extent to which teams are making progress related to the overarching goal and/or primary drivers for the Tribal Home Visiting CQIC. Program leads and home visitors from each grant recipient team should complete this survey independently. This survey will take about 5-10 minutes to complete and will be completed at the beginning, middle, and end of the CQIC. Time to complete the survey will be provided during the first CQIC Learning Session and final CQIC Learning Session. 
Please reach out to your Data TA Specialist if you have any questions.
Administrative Information
Cohort: ___________
Grant recipient program name: _____________________
Role on THV program:
☐ Program lead
☐ Home visitor
☐ Evaluator/data analyst/data staff
☐ Other: _________________
Survey Items
Please share the extent to which you agree or disagree with the following statements.
    1. My home visiting program has clearly defined organizational values related to relationship building and providing culturally responsive services.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    2. My home visiting program has identified skills for home visitors to focus on related to relationship building (e.g., active listening, empathy, reliability, clear communication, etc.). 
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    3. My home visiting program has identified skills for home visitors to focus on related to providing culturally responsive services (e.g., self-awareness, cultural humility, adaptability, etc.).  
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    4. My home visiting program supports home visitors to build and maintain skills to provide culturally responsive services.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
4a. (Optional) Please share any specific supports that have been most helpful in building and maintaining these skills?
___________________________________________________
___________________________________________________
    5. My home visiting program has structures in place that support staff wellbeing and prevent burnout (e.g., supervision support, workload flexibility, wellbeing policies).
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
5a. (Optional) Please share any supports or strategies that have been most helpful for staff wellbeing and preventing burnout (e.g., supervision, workload flexibility, wellness supports).
____________________________________________________
___________________________________________________
    6. I feel confident in my ability to build trusting, collaborative relationships with families.  
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    7. I have what I need to adapt home visiting services in ways that honor each family’s strengths, culture, and priorities while meeting program expectations (e.g., time, flexibility, support, resources).  
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
7a. (Optional) Please share any supports or resources that have been most helpful in allowing you to adapt services for families (e.g., time, flexibility, supervision, community partnerships).
____________________________________________________
____________________________________________________

    8. I feel confident integrating culture into how I build relationships with families.  
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    9. I feel confident integrating the family or community’s language into how I build relationships with families.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    10. I feel confident integrating my knowledge of the community into how I build relationships with families.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    11. I feel confident in my ability to integrate cultural values into home visiting services with families.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
    12. I am confident taking steps to reconnect with families when they are experiencing challenges engaging with the program (e.g. miss visits, lose connection).  

☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree

12a. (Optional) Please share any strategies or steps you have found most helpful when reconnecting with families (e.g., outreach methods, communication approaches, flexibility in scheduling).
________________________________________________
________________________________________________

    13. In supervision, I receive reflective support, guidance, and feedback that helps me strengthen my ability to build and nurture strong and culturally responsive relationships.
☐ Strongly agree
☐ Agree
☐ Disagree
☐ Strongly disagree
13 a. (Optional) Please share what types of supervision, guidance, or support have been most helpful to you (e.g., reflective supervision, feedback, coaching, team support).
____________________________________________________
____________________________________________________



    14. Please share anything else you would like us to know about your experiences building relationships or engaging with families.

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to support the implementation of the 2026 Tribal Home Visiting Continuous Quality Improvement Collaborative (CQIC) and to gather feedback from Tribal MIECHV program staff on their experiences implementing continuous quality improvement and culturally responsive, relationship-based home visiting practices. The information will be used to inform ACF’s training and technical assistance and to understand staff perspectives on capacity and practice change. Public reporting burden for this collection of information is estimated to average 0.17 hours (approximately 10 minutes) per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 9/30/2028. If you have any comments on this collection of information, please contact [email protected].