Other Home Visiting Programs Survey

OMB Control No: _____

Expiration Date: ______

Length of time for instrument: 0.10 hours

ATTACHMENT 18: OTHER HOME VISITING PROGRAMS SURVEY

5/29/2012

Other Home Visiting Programs Survey – Baseline

Nominated by the Participating Home Visiting Program

The U.S. Department of Health and Human Services has contracted with MDRC to evaluate the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program.

The Mother and Infant Home Visiting Program Evaluation (MIHOPE) is designed to build knowledge for policymakers and practitioners about the effectiveness of MIECHV.

Your answers will be kept confidential. Only the research team will have access to this information. Your answers will not be shared with anyone at your program or any other agencies. In our research reports, the information you provide will not be attributed by name to you or your individual program.

One objective of MIHOPE is to learn about the availability and characteristics of home visiting programs and parenting programs for infants in a community.

We have contacted you because [HOME VISITING PROGRAM] nominated your program as another home visiting program or parenting program for infants in the same community in which it is located. We are requesting that you complete this questionnaire to help us describe the availability and characteristics of home visiting and parenting programs for infants in the community.

• The questionnaire should take about 6 minutes to complete.

• If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank.

• In this questionnaire the term “program“ means a specific set of services offered within your agency, and the term “agency” means an organization that may offer one or more programs.

• We would appreciate your response by 5 p.m. on DD/MM/YYYY.

• If you have questions at any time during the study, please call Alexander Vazquez at MDRC toll-free at 1-877-311-6372 or email Alexander.vazquez@mdrc.org.

------------------------------------------------------------------------------------------------------------------------------

1. Please provide your agency’s street address, that is, the address of the place where clients would come to get center-based services or where home visitors have their desks. Please give this street address even if it is different from your agencies mailing address or its main offices.

Street Address:

City and state:

Zip code:

2. Does your program provide home visiting services to families with pregnant women or children ages birth to 5?

 No

 Yes

3. Are families with the following characteristics eligible to enroll in your program? CHECK ALL THAT APPLY.

 Families with pregnant women

 Families with children up to age 3 months

 Families with children ages 3 to 6 months

 Families with children ages 7 to 12 months

 Families with children ages 13 to 24 months

 Families with children ages 25 to 36 months

 Families with children ages 37 to 48 months

 Families with children ages 49 to 60 months

4. Does your program limit eligibility based on family income?

 No

 Yes

5. Does your program limit eligibility based on the number or level of risk factors?

 No

 Yes

6. Until what child age are families eligible to continue receiving services?

 Until age 12 months

 Until age 2

 Until age 3

 Until age 4

 Until age 5 or kindergarten entry

7. How often do families typically receive home visits?

 Weekly

 Twice a month

 Monthly

 Less than monthly

 Varies based on family need

 Varies based on child’s age

8. Does your program offer other services in addition to home visits? CHECK ALL THAT APPLY.

 Group parenting classes

 Play groups or other parent-child group activities

 Center-based child care

 Referrals to other parenting programs for infants (i.e., offered either within your own

agency or by another organization)

 Referrals to other community services

 Other (specify): _________

 None

9. Does your program implement a specific program model or use a specific curriculum? CHECK ALL THAT APPLY.

 Born to Learn

 Child FIRST

 Early Head Start

 Early Intervention Program

 Even Start

 Family Check-Up

 Family Connections

 Growing Great Kids

 Healthy Families America

 Healthy Start

 Healthy Steps

 HIPPY

 Incredible Years

 Nurse Family Partnership

 Nurturing Parenting Programs

 Parent-Child Home Program

 Parents As Teachers

 Resource Mothers

 SafeCare

 Triple P

 Other (specify): _________

10. Has your program received accreditation from the home visiting model your agency is implementing?

 Yes

 No

 Model does not require certification

 Don’t know

11. Have any of your program staff received certification from the home visiting model your agency is implementing?

 All staff have received certification

 Some staff have received certification

 No

 Model does not require certification

 Don’t know

12. What is your program’s total number of slots?

TOTAL FAMILIES: _________

13. What outcomes does your program target? CHECK ALL THAT APPLY.

 Prenatal health

 Maternal health outside of pregnancy

 Maternal substance use

 Maternal stress and mental health

 Anger management/Healthy adult relationships

 Domestic violence

 Family economic self-sufficiency

 Parenting to support child development

 Parenting to promote child health

 Birth outcomes

 Child injury

 Child illness

 Child physical growth

 Child communication, language, and literacy

 Child cognitive skills

 Child approaches to learning

 Child social behavior and emotional well-being

14. How many new families did your program enroll in the past 12 months?

NEW FAMILIES: _________

15. How long has your home visiting program been in operation in this community?

LENGTH OF TIME: Years _________ Months __________

16. What is the average cost of your program per client? [Complete any that apply.]

Weekly:	$ _______________
Monthly:	$ _______________
Total cost for program participation:	$ _______________