Form 1 Model Eligibility Survey

OMB Control Number: 0906-XXXX

OMB Expiration Date: MM/DD/20XX

MIECHV Program Model Eligibility Review Survey

The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program supports families with young children up to kindergarten entry living in at-risk communities. Federal law for the program requires MIECHV home visiting programs to deliver services using early childhood home visiting models that meet certain requirements, including Department of Health and Human Services (HHS) criteria for evidence of effectiveness,¹ as determined by the Home Visiting Evidence of Effectiveness (HomVEE) review. However, not all models designated as evidence-based by HomVEE meet MIECHV statutory requirements² such that they may be used to carry out the MIECHV Program in fidelity to applicable program requirements. To address this, HRSA developed the MIECHV Program Model Eligibility Review Survey³ to identify service delivery models that meet both HHS criteria for evidence of effectiveness, as determined by HomVEE, and applicable MIECHV statutory requirements, and, therefore, may be used by MIECHV awardees to provide home visiting services through the MIECHV Program. This survey will validate whether evidence-based models, as determined by HomVEE, align with the MIECHV Program’s statutory requirements to ensure that models used by MIECHV awardees (and their local implementing agencies) to deliver MIECHV Program services effectively support home visiting programs in meeting core components of the MIECHV Program, including those added during the program’s 2022 reauthorization.⁴

Each question in this survey focuses on key aspects of home visiting models that must align with MIECHV statutory requirements for a model to be implemented using MIECHV Program funds.

Follow these instructions to complete the survey:

• Read each question carefully.

• Choose the answer that best fits how your model is intended to work.

  • We acknowledge that you may tailor services to specific family needs or modify service delivery during emergency situations, such as public health emergencies or weather events. This survey is concerned with the intent or design of your model, not how you adjust the model for individual families or emergencies.

• If you choose “unsure,” add details to explain your answer and provide more context related to the topic of the question. Including details about how your model is designed to be implemented and why you are unsure how to answer will help HRSA understand the source of your uncertainty. The types of details you could provide could include, but are not limited to, explanations, limited excerpts from fidelity standards, or limited excerpts from guidance issued to supervisors.

• There may be limited opportunity for follow-up discussion once your responses to the survey are under review. Consider your response in the “unsure” text box the primary opportunity to explain why your model may or may not fit the question criteria.

Thank you for taking the time to answer these important questions carefully.

Public Burden Statement: This survey is intended to validate that early childhood home visiting models that meet HHS criteria for evidence of effectiveness, as determined by HomVEE review, align with the MIECHV Program’s statutory requirements. The information gathered will contribute to HRSA’s administration of the MIECHV Program, which requires funding recipients to conduct the program using one or more service delivery models that meet statutory requirements. 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-XXXX and it is valid until XX/XX/20XX. This information collection is required to obtain or retain a benefit.⁵ Your responses will be kept private to the extent allowed by law. Public reporting burden for this collection of information is estimated to average 3 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 Office, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Model Status

1. Is your model currently active (that is, currently being implemented)?

• Yes

• No

1. If your model is active, when did your model first begin delivering services? Please provide month and year (for example, January 2024).

2. If your model is inactive, what were the dates of services? Please provide month and year (for example, January 2023 – January 2024).

Model Eligibility

2. Does your model serve pregnant women or families with children from birth through kindergarten entry (that is, through age 5)?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: please respond “Yes” if the model’s intended population includes (but need not be limited to) this population, which may include primary caregivers, such as grandparents and foster parents. Models are not required to serve families throughout the entire age range from birth through kindergarten entry. Models may serve families with children within this age range (for example, ages 2 to 4).

3. Does your model have eligibility requirements to support home visiting programs’ ability to prioritize providing services to at-risk expectant and new parents and families?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: “at-risk expectant and new parents and families” includes (but need not be limited to) the high-priority populations identified in MIECHV Program statute,⁶ which includes:

• Families who reside in at-risk communities with concentrations of premature birth, low-birth weight infants, infant mortality, or other indicators of at-risk prenatal, maternal, newborn, or child health; poverty; crime; domestic violence; high rates of high school dropouts; substance misuse; unemployment; or child maltreatment

• Low-income families

• Pregnant women younger than age 21

• Families that have a history of child abuse or neglect or have had interactions with child welfare services

• Families that have a history of substance abuse or who need substance use treatment

• Families that have tobacco users in the home

• Families that are or have children with low student achievement

• Families with children with developmental delays or disabilities

• Families who, or that include individuals who, are serving or formerly served in the Armed Forces

4. Can your model be implemented in a voluntary setting?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Model Design and Delivery

5. Is your model designed so that home visitors work to build strong, positive relationships with families to improve child and family outcomes?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

6. Do home visitors deliver a specific set of services to participants as part of your model?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: please respond “Yes” if your model uses a curriculum, a menu of modules that can be offered, or guidelines about topics that may be covered, whether by visit, developmental milestones, or some other structure. Content of visits may be tailored to family need.

7. Do home visitors deliver services through a specific set of interactions with participants as part of your model?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: please respond “Yes” if your model has, for example, standard guidance on the types of interactions that home visitors should have with participants, such as frequency and duration of home visits. Frequency, duration, and type of visits may be tailored to family need.

8. Was your model designed for delivery in the home or has it been adapted and tested for delivery in the home?

• Yes, designed for delivery in the home

• Yes, adapted and tested for delivery in the home

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: a model designed for delivery in the home, or adapted and tested for delivery in the home, may sometimes deliver home visits in other locations, such as a homeless shelter, residential treatment facility, or other location where participants feel safe, or virtually. The location and type of home visit may be tailored to family needs and can be in the location that feels most at home to them. Even if visits are sometimes delivered in a different location or are tailored to individual family needs, a model should respond “Yes” if the model is designed for or adapted and tested for delivery in the home.

9. Is your model designed or adapted to deliver more than half (more than 50%) of its program content through home visits?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: for example, consider a model designed or adapted to deliver the “Thriving Tots” parenting curriculum. The curriculum includes 20 lessons. If the model delivers 11 of the lessons to participants through home visits, the answer would be “Yes”: more than half of program content for the model would be delivered through home visits (55%, or ). If the model were designed or adapted to deliver 10 of the lessons during pediatric office visits and the other 10 during home visits, the answer would be “No”: more than half of program content is not provided through home visits.

Note: if you select “Unsure,” include numbers as appropriate in your explanation.

Note: a model designed for delivery in the home, or adapted and tested for delivery in the home, may sometimes deliver home visits in other locations, such as a homeless shelter, residential treatment facility, or other location where participants feel safe, or virtually. The location and type of home visit may be tailored to family needs and can be in the location that feels most at home to them. Models should base their responses on the design or adaptation of the program, not on adjustments made for individual family needs.

10. Does your model require or recommend a defined schedule for the delivery of services or tailor the schedule of services to meet family needs?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Program Standards Associated with High-Quality Service Delivery and Continuous Quality Improvement

11. Does your model support home visiting programs’ ability to deliver ongoing services to parents and families to improve family outcomes as a result of model implementation, rather than primarily operating universal or targeted client intake programs?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: while each home visiting model has its unique aspects, in general, home visiting involves three main intervention activities conducted through one-on-one interactions between home visitors and families: assessing family needs, educating and supporting parents and families, and referring families to needed services in the community. Delivering “ongoing services” can involve a variety of strategies and activities used by home visitors in relationship with client families that continues for several sessions, including (but not limited to) setting goals with caregivers and creating plans for meeting those goals, helping caregivers resolve problems, helping parents and children build better relationships, intervening during crises, providing information on children’s developmental stages, commenting on parenting, working to strengthen families’ support networks, and providing emotional support, pamphlets, or other materials. These strategies and activities can target a variety of outcomes and can be based on curricula or model-specific guidelines or family needs and interests, or both.⁷

12. Is your model designed or adapted to support home visiting programs’ ability to deliver at least 1 in-person home visit to each client family every 12 months during the period when the model is designed to be in use?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: a model designed for delivery in the home, or adapted and tested for delivery in the home, may sometimes deliver home visits in other locations, such as a homeless shelter, residential treatment facility, or other location where participants feel safe, or virtually. The location and type of home visit may be tailored to family needs and can be in the location that feels most at home to them. For this question, please respond “Yes” if each client family would receive at least one in-person (that is, non-virtual) home visit if the model is implemented as intended.

13. Does your model provide ongoing support to home visiting programs to implement the model with fidelity in the United States (including tribal nations in the United States or within any of the U.S. territories)?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: “ongoing support to home visiting programs to implement the model with fidelity” may include (but is not limited to) providing trainings, training materials, technical assistance, or other types of help to programs implementing the model.

Please consider the following definition for item 14:

• Continuous quality improvement is a systematic approach to specifying the processes and outcomes of a program or set of practices through regular data collection and the application of change strategies that may lead to improvements in performance.

14. Does your model support home visiting programs’ continuous quality improvement?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: this could include (but is not limited to) processes, systems, tools, or other strategies to help home visiting programs implementing the model measure how services delivered help families and communities, use data to improve performance, or otherwise create and carry out plans for continuous quality improvement.

Please consider the following definition for item 15:

• In-service education or training (sometimes referred to as “ongoing training” or “professional development”) is education or training that home visitors participate in during their employment.

15. Does your model require or recommend that home visiting programs provide some pre-service and in-service education or training on the model for all home visitors and home visiting supervisors? Please specify using the boxes below. Check all that apply.

	Pre-service training	In-service training	Neither	Unsure
Home visitors
Home visiting supervisors

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

16. Does your model require that home visitors receive training to achieve all the same competencies whether they deliver services virtually or in person?

• Yes

• No

• Unsure

• The model does not provide or allow for virtual services (in non-emergency situations)

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: the same home visitor may deliver services in person and virtually. Respond “Yes” if your model requires training for home visitors to achieve the same competencies in both venues.

17. Does your model establish educational requirements and/or competencies around knowledge, skills, abilities, or experience to support home visiting programs’ ability to ensure that home visitors and home visiting supervisors are able to deliver services effectively and with fidelity to the model?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: models may allow home visitors and home visiting supervisors to achieve educational requirements and/or competencies at any time in the program cycle, including at the hiring stage or over time after hiring.

Note: if you respond “Unsure,” please address both home visitors and home visiting supervisors in your explanation.

18. Does your model have requirements or recommendations that support home visiting programs’ ability to provide supervision for home visitors that supports establishing or strengthening professional competencies specified by the model as necessary for the delivery of home visiting services?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

19. Does your model support home visiting programs’ ability to maintain the quality of supervision for home visitors?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: this could include (but is not limited to) training for supervisors, guidelines about the type of supervision (for example, reflective supervision, administrative supervision, or clinical supervision) or frequency of supervision to provide, reporting requirements related to supervision, or other strategies for ensuring quality of supervision.

20. Does your model support home visiting programs’ ability to connect program participants to community resources and supports?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: this could include (but is not limited to) protocols, training materials, standard operating procedures, supervisory direction, or other types of advice or information provided to programs implementing the model.

Model Support and Documentation

Please consider the following definitions for items 21 and 22:

• A national organization may be in the United States, including tribal nations or within any of the U.S. territories, or based outside the United States.

• An organization is “national” if it has an office that is able to support implementation in two or more states, tribal nations, territories, or regions, or similarly defined geographic areas outside the United States. “Able to” means the organization is currently supporting implementation in two or more states, tribal nations, or territories, or the organization indicates that it would support implementation in two or more states, tribal nations, or territories.

• An institution of higher education (IHE) may be an accredited community college, college, or university in the United States or another country. Accredited means an IHE officially recognized by a national body or state agency, and, if in the United States, approved by the Secretary of Education.

• “Supported” means providing trainings, technical assistance, or other types of help to programs implementing the model. “Supported” does not include program evaluation services.

21. Please check all that apply to your model:

• Model was developed by a national organization

• Model was developed by an IHE

• Model’s implementation is currently supported by a national organization

• Model’s implementation is currently supported by an IHE

• Model’s implementation is currently supported by a tribal nation, tribal organization, state, or territorial organization that would support implementation in a second tribal nation, state, or territory

• None of these

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

22. If you indicated in item 21 that your model was developed by or its implementation is currently supported by either a national organization or IHE, can the national organization or IHE provide implementing agencies with documentation of comprehensive program standards, including fidelity standards or implementation guidance?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Please consider the following definition for item 23:

• Fidelity standards are requirements developers create to document how to operationalize their model’s self-defined core components. They are designed to ensure implementation achieves a model’s intended outcomes. Fidelity standards may allow for flexibility to meet the needs of families or communities.

23. Does your model have fidelity standards that describe how the model is to be implemented?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

24. Does your model support home visiting programs’ ability to monitor fidelity of program implementation on an ongoing basis?

• Yes

• No

• Unsure

If you select “Unsure,” please include details about your model and why you are unsure how to respond.

Note: this could include (but is not limited to) protocols, training materials, standard operating procedures, or other types of advice or information provided to programs implementing the model.

1 Administration for Children and Families (ACF). “HHS Criteria for Evidence-Based Models.” Home Visiting Evidence of Effectiveness. Department of Health and Human Services. Accessed January 8, 2025. https://homvee.acf.hhs.gov/about-us/hhs-criteria.

2 42 U.S.C. 711 establishes statutory requirements for the MIECHV Program.

3 HRSA, HHS. “Agency Information Collection Activities: Proposed Collection: Public Comment Request; Information Collection Request Title: Maternal, Infant, and Early Childhood Home Visiting Program Model Eligibility Review Survey.” Federal Register 90, no. 5 (January 8, 2025): 1508. https://www.federalregister.gov/d/2025-00129.

4 Section 6101 of the Consolidated Appropriations Act, 2023, P.L. 117-328, amended Section 511 of the Social Security Act, as added by the Patient Protection and Affordable Care Act, P.L. 111-148, Section 2951, and extended appropriated funding for the MIECHV Program through FY 2027.

5 42 U.S.C. 711(d)(3)(A)(i)

6 42 U.S.C. 711(d)(5)

7 See the following reports for more information about ACF’s findings about educating and supporting parents and families and the other two types of activities in home visiting: Impacts on Family Outcomes of Evidence-Based Early Childhood Home Visiting (January 2019) and Implementation of Evidence-Based Early Childhood Home Visiting (October 2018).

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