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Appendix Ii

ICR 201502-0970-010 · OMB 0970-0456 · Object 56537701.

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January 27, 2015

Family Connection Cross-site Evaluation Survey
[CLUSTER NAME]
Project Leader Survey
[PROJECT NAME]

SURVEY LEAD-IN AND INSTRUCTIONS PAGE
Thank you for taking the time to complete this survey about the Family Connection – [CLUSTER NAME]
project, also known as the [INSERT PROJECT NAME HERE]. Your input is very valuable to the cross-site
evaluation as we work toward understanding and synthesizing data on how grantees implement services
and the impact of the services on the organization, community, and children and families.
This survey is about the [INSERT PROJECT NAME HERE]. Please answer all questions in regard to your
involvement with [INSERT PROJECT NAME HERE].
The “grantee organization” is the recipient of Family Connection Federal funding. The grantee
organization is [INSERT GRANTEE ORGANIZATION NAME HERE].
Your survey response is confidential and will not be shared with other members of the project team,
project partners, the Children’s Bureau, or other Federal partners. All data collected through this survey
will be aggregated for analysis and reporting purposes; information that identifies individual participants
will not be used.
The survey will take approximately 45 minutes to complete. For your convenience, you can enter and
exit the survey as many times as you like to answer the survey items. Your response is not final until you
select “Submit” at the end of the survey.
To begin the survey now, please click here: CONTINUE

Note: ___________ = pre-filled information and/or an action conducted by the web survey system (i.e.,
no action required by the survey respondent).
OMB NO: TBD
EXPIRATION DATE: TBD
Burden Statement: Public reporting burden for this collection of information is estimated to average .75
hours per respondent. These estimates include the time for reviewing instructions, and completing and
reviewing the collection of information. 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.

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January 27, 2015
Evaluation ID:
Respondent:
Project Role:
Organization:

__________
____________________
__________
__________
Family Connection Cross-site Evaluation Survey
[CLUSTER NAME]
Project Leader Survey

A. BACKGROUND
The following questions ask about your background with the project and the grantee organization.
The “grantee organization” is the recipient of Family Connection Federal funding. The grantee
organization is [INSERT GRANTEE ORGANIZATION NAME HERE].
1. Please verify your primary role on the Family Connection – [CLUSTER NAME] project. (Check one)
a. Executive Leaders (e.g., President, CEO)
b. Project Director
c. Other Project Leaders (e.g., Deputy Project Director, Program or Project Manager, service
provider Supervisor)
d. Service Provider (e.g., advocate, case manager, case worker, counselor, educator, facilitator,
nurse, mentor, therapist, etc.)
e. Public Child Welfare Partner representative
f. Community Partner representative
g. Lead Evaluator/Principal Investigator
h. Evaluation Team Member
i. Other (specify): _______________________________
2. How long have you been in this role for the Family Connection project?
a. Less than 1 year
b. 1+ to 2 years
c. 2+ to 3 years
3. How long have you worked for your current organization?
a. Less than 1 year
b. 1+ to 2 years
c. 3+ to 5 years
d. 5+ to 10 years
e. Over 10 years

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January 27, 2015

B. PROJECT PLANNING AND READINESS
The next few questions ask you to reflect upon the grantee organization’s planning and readiness for
implementing the Family Connection project.
The “grantee organization” is the recipient of Family Connection Federal funding. The grantee
organization is [INSERT GRANTEE ORGANIZATION NAME HERE].
1. Were you involved in planning the Family Connection project (e.g., writing the grantee’s funding
application, planning during the initial start-up period, etc.)
a. Yes
b. No
[If NO, skip to Section C].
2. What are the top three reasons the grantee organization sought to incorporate Family Connectionfunded services into your practice?
a. Model/services already a practice within the organization (e.g., staff members already trained)
b. Model/services complement existing practices within organization
c. Model/services a good “fit” for the population served (e.g., cultural fit, etc.)
d. Model/services a good “fit” for the organization (e.g., matched philosophy)
e. Model/services an opportunity to increase the organization’s capacity to serve families
f. Benefits of the model/services described in academic or other literature
g. Key partner(s) had experience with the model
h. Local community assessments indicated need for model/services
i. Other (specify): _______________________________
3. Do you know what other project staff members and partners were engaged in planning the Family
Connection project (e.g., writing and/or otherwise contributing to the grantee’s funding application,
planning during the initial start-up period, etc.)?
a. Yes
b. No
[If NO, skip to B5]
4. What other project staff members and partners were engaged in planning the Family Connection
project? (Check all that apply)
a. Executive Leaders (e.g., President, CEO)
b. Project Director
c. Other Project Leaders (e.g., Deputy Project Director, Program or Project Manager, service
provider Supervisor, etc.)
d. Service Provider (e.g., advocate, case manager, case worker, counselor, educator, facilitator,
nurse, mentor, therapist, etc.)
e. Public Child Welfare Partner representative
f. Community Partner representative
g. Lead Evaluator/Principal Investigator
h. Evaluation Team Member(s)
i. Prior Family Connection grantee(s)

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File Type	application/pdf
File Title	Appendix Ii
File Modified	2015-01-29
File Created	2015-01-28