A.2.2.b Survey

Appendix A A.2.2.b–9

Source: Visits: Within X Days of 6 month Mode: Self-administered (Mail-in) Estimated Time:		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

6 Month Father Questionnaire

6 months

Instructions

1	This booklet contains questions about how you feel, your child’s behavior and how you and your partner divide the duties of raising a child.
2	Use a No. 2 pencil or a blue or black ink pen only. Do not use a felt-tipped pen or a red ink pen.
3	Make solid marks that fill the oval completely. Do not use a or an to record an answer.
4	If you need to change an answer, be sure to erase or mark out the unwanted marks completely.
5	Mark only one response for each question, unless otherwise directed.

These first questions are about different things you may do as a parent.

1. Please indicate how often do you feel the following ways or do the following things.

How often do you feel the following ways or do the following things:	All of the Time	Some of the Time	Rarely	Never
a. Talk a lot about your child to friends and family?	O	O	O	O
b. Carry pictures of your child with you wherever you go?	O	O	O	O
c. Find yourself thinking about your child?	O	O	O	O
d. Think holding and cuddling your child is fun?	O	O	O	O
e. Think it’s more fun to get your child something new than to get yourself something new?	O	O	O	O

2. How strongly do you agree or disagree with the following statement:

Babies have to learn they can’t be picked up every time they cry.

O Strongly agree

O Agree

O Neither agree nor disagree

O Disagree

O Strongly disagree

3. Do you read or look at books with your child?

O Yes

O No  Go to Question 5

4. How often do you read or look at books with your child?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

5. Does your child watch TV and/or DVDs?

O Yes

O No  Go to Question 7

6. How often does your child watch TV and/or DVDs?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

7. How often do you play with toys with your baby?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

8. How often do you go for walks with your baby?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

The next set of questions asks about how you think most young children act, how they grow, and how to care for them. Please answer each of the following questions based on young children, in general, not about your child and how he or she acts. Think about what you know about young children you have had contact with or anything you have read.

9. For each of the following statements, indicate whether, for most children, you agree or disagree with the statements, or are not sure.

	Agree	Disagree	Not Sure
a. All infants need the same amount of sleep?	O	O	O
b. A young brother or sister may start wetting the bed or thumbsucking when a new baby arrives in the family?	O	O	O

11. Next, is a list of ways you might have felt or behaved in the past 7 days. Please indicate how often have you felt or thought a certain way.

How often have you felt or thought:	Rarely or none of the time (less than once a week)	Some or a little of the time (1–2 days a week)	Occasionally or a moderate amount of the time (3–4 days a week)	Most or all of the time (5–7 days a week)
a. You were bothered by things that usually don’t bother you.	O	O	O	O
b. You did not feel like eating; your appetite was poor.	O	O	O	O
c. You felt that you could not shake off the blues even with the help of your family or friends.	O	O	O	O
d. You felt you were just as good as other people.	O	O	O	O
e. You had trouble keeping your mind on what you were doing.	O	O	O	O
f. You felt depressed.	O	O	O	O
g. You felt that everything you did was an effort.	O	O	O	O
h. You felt hopeful about the future.	O	O	O	O
i. You thought your life has been a failure.	O	O	O	O
j. You felt fearful.	O	O	O	O
k. Your sleep was restless.	O	O	O	O
l. You were happy.	O	O	O	O
m. You talked less than usual.	O	O	O	O
n. You felt lonely.	O	O	O	O
o. People were unfriendly.	O	O	O	O
p. You enjoyed life.	O	O	O	O
q. You had crying spells.	O	O	O	O
r. You felt sad.	O	O	O	O
s. You felt that people disliked you.	O	O	O	O
t. You could not get “going.”	O	O	O	O

12. Most people have disagreements in their relationships. Please indicate the approximate agreement or disagreement between you and your partner for each of the following items.

	Always Agree	Almost Always Agree	Somewhat Agree	Hardly Ever Agree	Never Agree
a. Handling family matters	O	O	O	O	O
b. Matters of recreation	O	O	O	O	O
c. Religious matters	O	O	O	O	O
d. Demonstrations of affection	O	O	O	O	O
e. Friends	O	O	O	O	O
f. Sex relations	O	O	O	O	O
g. Conventionality (correct or proper behavior)	O	O	O	O	O
h. Philosophy of life	O	O	O	O	O
i. Ways of dealing with parents or in-laws	O	O	O	O	O
j. Aims, goals, and things believe important	O	O	O	O	O
k. Amount of time spent together	O	O	O	O	O
l. Making major decisions	O	O	O	O	O
m. Household tasks	O	O	O	O	O
n. Leisure time interests and activities	O	O	O	O	O
o. Career decisions	O	O	O	O	O

13. How often:	All of the Time	Most of the Time	Sometimes	Hardly Ever	Never
a. Do you discuss or have you considered divorce, separation, or terminating your relationship?	O	O	O	O	O
b. Do you or your mate leave the house after a fight?	O	O	O	O	O
c. In general, do you think that things between you and your partner are going well?	O	O	O	O	O
d. Do you confide in your partner?	O	O	O	O	O
e. Do you ever regret that you married your partner (or lived together)?	O	O	O	O	O
f. Do you and your partner quarrel?	O	O	O	O	O
g. Do you and your partner “get on each other’s nerves”?	O	O	O	O	O

14. How often:	Every day	Almost every day	Sometimes	Hardly ever	Never
a. Do you kiss your partner?	O	O	O	O	O
b. Do you and your partner engage in interests together?	O	O	O	O	O

15. How often do you:	Never	Less than once a month	Once or twice a month	Once or twice a week	Once a day	More often
a. Have an interesting chat?	O	O	O	O	O	O
b. Laugh together?	O	O	O	O	O	O
c. Calmly discuss something?	O	O	O	O	O	O
d. Work together on a project?	O	O	O	O	O	O

16. Were the items below problems in your relationship during the past FEW WEEKS?

YES NO

a. Being too tired for sex O O

b. Not showing love O O

17. Which one response best describes the degree of happiness in your relationship?

O Very unhappy

O Somewhat unhappy

O Fairly happy

O Mostly happy

O Very happy

18. Which one of the following statements best describes how you feel about the future of your relationship?

O I want desperately for my relationship to succeed, and would go to almost any length to see that it does.

O I want very much for my relationship to succeed, and will do all I can to see that it does.

O I want very much for my relationship to succeed, and will do my fair share to see that it does.

O It would be nice if my relationship to succeed, but I can’t do much more than I am doing now to help it succeed.

O My relationship can never succeed, and there is no more that I can do to keep the relationship going.

19. Now I am going to ask you about work clothing. Some people work at jobs where their skin, clothes, or shoes get dirty or stained. Think about everyone in your household. Does anyone ever routinely come home with dirty or stained skin, work clothes, or shoes? By “dirty” or “stained” we mean their skin or clothes have dust, grease, or other visible chemical spots on them.

O Yes

O No  Go to Page 8

20. Who is it that comes home with dirty or stained skin, work clothes, or shoes? Is it:

O You

O Others in the home

O Both you and others in the home

The following question is about those who come home with dirty or stained clothing.

21. How often do you or anyone in your household:

	Every Day	5–6 Times a Week	3–4 Times a Week	1–2 Times a Week	Never
a. Come home from work with dirty hands or skin?	O	O	O	O	O
b. Wear dirty work shoes inside your home?	O	O	O	O	O
c. Wear dirty work clothes inside your home?	O	O	O	O	O

22. How often do you or anyone in your household wash work clothes at home? O Every day O 5–6 times a week O 3–4 times a week O 1–2 times a week  Go to Page 8 O Never  Go to Page 8 23. Are your work clothes washed separately from other clothes? O Yes O No

24. What types of materials have you or anyone in your household brought home on work clothes or shoes? O Dirt O Wood dust O Grease O Pesticides O Metal dust O Coal or mining dust O Animal hair O Fibers (such as asbestos or fiberglass) O Other __________________ Specify

The next questions are about your child’s exposure to environmental tobacco smoke.

25. Do you currently smoke cigarettes or use any other tobacco products? O Yes O No 26. Including yourself, how many smokers live in your home now? ___________ NUMBER OF SMOKERS 27. Do you or does anyone smoke inside the house? O Yes O No

28. Which of the following statements describes the rules about smoking inside your home now? O No one is allowed to smoke anywhere inside my home, O Smoking is allowed in some rooms at some times, or O Smoking is permitted anywhere inside by home. 29. On average, about how many hours per day do people smoke in the same room as your baby, or near enough that he/she can smell the smoke? Please consider all the places your baby is during the day, including at home, at daycare, or some other place. If he/she is not exposed to smoke, enter “0”. ___________ NUMBER OF HOURS

These next questions are about the language spoken in your home.

30. Is there any language other than English regularly spoken in your home?

O Yes

O No  Go to End of Survey

31. What languages other than English are spoken in your home?

(SELECT ALL THAT APPLY).

O Arabic O Korean

O Chinese O Polish

O Filipino language O Portuguese

O French O Spanish

O German O Vietnamese

O Greek O Sign language

O Italian O Some other language

O Japanese __________________

Specify

32. Is English also spoken in your home?

O Yes

O No

33. What is the primary language spoken in your home?

O English O Japanese

O Arabic O Korean

O Chinese O Polish

O Filipino language O Portuguese

O French O Spanish

O German O Vietnamese

O Greek O Sign language

O Italian O Some other language

__________________

Specify

34. How often do you use a language other than English in speaking to your {BABY}?

O Never

O Sometimes

O Often

O Very often

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